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ENVIRONMENTAL HEALTH DEP/TAN <br /> SAN JOAQUIN COUNTY <br /> 1868 E. Hazelton Ave., Stockton, California 9 <br /> Telephone: (209) 468-3420 Fax: (209) 468- <br /> APPLICATION FOR UNDERGROUND STORAGRETROFIT OR PIPING REPAIR PERTHIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMI❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT ❑ <br /> F EPA Site# Project Contact&Telephone# <br /> � Facility Name '-'-CAJE L G T ZS iL L 0 Phone# 000 — 5(p - (p 0 <br /> Address <br /> T Cross Street 01 <br /> Y Owner/Operators 1 l,0 r l (LAvI ej Phone# e00- O <br /> G Contractor Name j D 0�-- G7 6jt;— C "Up t V\ Phone# 90-q—0-1j f�-'7 Zo b <br /> T Contractor Address g5gs LUCAS 2anch i2j•/7 IAC t1 CVG kn 9 CA Lic# ��3�( Class �K� <br /> A lnsurerlt,J�66t111100AL 10SJ 2A uGE aW P Work Comp# N 1®D <br /> C ICC Technician's Name ann Expiration Date <br /> T et 00 AhiCtY\ �!) �Z P S 3D ZJ1'I <br /> R ICC Installer's Name a 114x-A 601,NeL �, q 3�� Expiration Date $ 30 Zv( <br /> Tank system work area Tank Size/ Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 1/2,etc.) ! Installed <br /> T <br /> A <br /> N <br /> K 1 <br /> F <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See A achment With Conditions) <br /> A <br /> N Plan Reviewers Name / Date <br /> APPLICANT MUST PERFORM ALL WORK IN AC ORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONMENTAL HEALT DEPARTMENT.OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WF)1CH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CAYIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE P MANCE OF HE WC)RK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO, RKER'S COMPENSATION LAWS <br /> OF CALIFORNIA. <br /> Applicant's Signature Title 4 Date j�,C, <br /> t <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If <br /> the party designated b6low is different than the permit applicant, e.g. property owner, the party must acknowledge this <br /> responsibility for`thie,billing by signature and date below. (� <br /> NAME �T V�- TITLE �y I✓� I�' PHONE# C/ `til 75 <br /> ADDRESS g- �AOOk I�OAO ZI a �A 6 Al onAb <br /> SIGNATURE DATE a' Z L) <br /> EH230038(revised 1 -11-15) 2 <br />